Description

Location: Jackson North Medical Center – JNMC Case Management

Address: 160 NW 170th St, North Miami Beach, FL 33169

Shift: M-F 8:30am-5pm

Position Summary:
Clinical Denials Coordinator is responsible for reviewing denied accounts, establishing trends, identifying operational improvement opportunities, working with the impact areas to correct and improve weaknesses within their processes that leads to denials. Audit accounts and address clinical issues leading to denials. Work with payors on focused audits and coordinate the clinical audits. Work closely with the denial agencies on reporting and placements.

Duties & Responsibilities:
Audit denied or potentially denied accounts to determine true denial reason. Collaborate with denial agencies on identifying trends and reporting to denial committees. Work closely with payors and JHS managed care department and manage projects focused on resolving denials and improving recoveries. Coordinate denial committee meetings at each facility and ensure reviews and reports are completed timely and presented at each meeting. Assist the CBO in reconciling placements and recoveries monthly to ensure Siemens and Connance are in balance. Coordinate with CFO's and denial committee teams at each facility to ensure net denial targets are met. Crosstrain and assist with invoice reconciliation as needed. Assist with internal and external audit requests relating to denials as requested by management. Role models behaviors of service excellence and CARE values (Compassion, Accountability, Respect and Expertise). Performs other related duties as assigned.

Qualifications

Experience:
Generally requires 3 to 5 years of related experience.

Education:
Bachelor's in Science required with a certification as a PA, LPN or RN. Master's degree preferred and/or certification as ARNP or Foreign Medical Graduate.

License Certification:
Valid PA, LPN or RN is preferred.

Knowledge Skill Abilities:
Ability to analyze, organize and prioritize work accurately while meeting multiple deadlines. Ability to communicate effectively in both oral and written form. Ability to handle difficult and stressful situations with critical thinking and professional composure. Ability to understand and follow instructions. Knowledge and skill in use of job appropriate technology and software applications. Unit Specific: Experience completing clinical and chart audits required. Interqual/Milliman criteria and evidence based protocol knowledge required. Case management, revenue cycle and contract interpretation experience preferred. Excellent analytical, verbal and written skills.

Physical Demands:
Job function is sedentary in nature and requires sitting for extended periods of time. Function may require frequent standing or walking. Must be able to lift or carry objects weighing up to 20 pounds. Jobs in this group are required to have close visual acuity to perform activities such as: extended use of computers, preparing and analyzing data and analytics, and other components of a typical office environment. Additional information and provision requests for reasonable accommodation will be provided by the home unit/department in collaboration with the Reasonable Accommodations Committee (RAC).

Work Environment:
Jobs in this group are required to function in a fast paced environment with occasional high pressure or emergent and stressful situations. Frequent interaction with a diverse population including team members, providers, patients, insurance companies and other members of the public. Function is subject to inside environmental conditions, with occasional outdoor exposures. Possible exposure to various environments such as: communicable diseases, toxic substances, medicinal preparations and other conditions common to a hospital and medical office environment. May wear Personal Protective Equipment (PPE) such as gloves or a mask when exposed to hospital environment outside of office. Reasonable accommodations can be made to enable people with disabilities to perform the described essential functions. Additional information and provision requests for reasonable accommodation will be provided by the home unit/department in collaboration with the Reasonable Accommodations Committee (RAC).